AIDS dementia complex (ADC), also known as HIV dementia, HIV encephalopathy and HIV-associated dementia, is a common neurologic disorder associated with HIV infection and AIDS. Dementia occurs when neurocognitive impairment is severe enough to interfere with an individual's daily activities.

The human immunodeficiency virus, also known as HIV infection, is a retrovirus that causes AIDS (autoimmunodeficiency syndrome). The retrovirus primarily attacks the body's immune system, making the body extremely vulnerable to opportunistic infections (infections that occur in immunocompromised individuals).

HIV is transmitted from person to person via bodily fluids. It can be spread by sexual contact with an infected person, by sharing needles/syringes with someone who is infected, or, less commonly (and rare in countries where blood is screened for HIV antibodies), through transfusions with infected blood. HIV has been found in saliva and tears in very low quantities and concentrations in some AIDS patients. However, contact with saliva, tears or sweat has never been shown to result in HIV transmission.

The opportunistic infections that are associated with HIV do not cause ADC. Instead, HIV causes ADC. AIDS dementia complex is a metabolic encephalopathy (degenerative brain disease), which is caused by HIV infection and fueled by immune activation of brain macrophages (large white blood cells that engulf foreign substances in the body) and microglia (brain cells that digest dead neurons). These cells are infected with HIV and secrete neurotoxins that ultimately destroy neurons (brain cells), which cannot be regenerated. Therefore, the damage caused by ADC is irreversible.

In most cases, ADC occurs after several years of HIV infection. It is associated with low CD4+ T-cell levels (less than 200 cells/microliter of blood) and high plasma viral loads. ADC is considered an AIDS-defining illness, which means it is often the first sign of the onset of AIDS.

The condition is identified when an increase of monocytes and macrophages enter the central nervous system (CNS). In addition, patients experience gliosis (rapid production of glial cells in the brain), pallor of myelin sheaths (loss of the fatty layer surrounding the axons of nerves in the brain), abnormal dendritic cells and abnormal neuronal apoptosis (programmed cell death).

The condition causes cognitive impairment, motor dysfunction, speech problems and behavioral changes. While the progression of dysfunction is variable, ADC can be fatal if left untreated.

Highly active antiretroviral therapy (HAART) has led to a decline of ADC in developed countries. The frequency of ADC has declined from 30-60% of people infected with HIV to less than 20%. The therapy may not only prevent or delay the onset of ADC, but it may also improve mental function in patients who already have ADC.

Despite the widespread use of HAART, some people with HIV still develop ADC. Others cannot tolerate HAART. For these people, prognosis is usually poor. The dementia worsens over several months until the patient is no longer able to care for himself or herself. He or she becomes bedridden, unable to communicate and dependent on others for care.

The opportunistic infections that are associated with HIV do not cause ADC. Instead, HIV causes ADC. However, researchers do not know how the virus damages the brain cells.

HIV may affect the brain through several mechanisms. The HIV proteins may damage nerve cells directly or indirectly.

Many researchers suggest that HIV damages the neurons indirectly. According to some researchers, HIV either infects or activates macrophages and microglia. These cells then produce toxins that can stimulate a series of reactions, which instruct neurons to kill themselves (abnormal neuronal apoptosis). The infected macrophages and microglia also appear to produce chemokines and cytokines (proteins that mediate and regulate immunity, inflammation and hematopoiesis), which can also affect neurons, as well as astrocytes. The affected astrocytes, which normally protect and nurture neurons, may now end up damaging them.

While the progression of dysfunction is variable, it is regarded as a serious complication and, if left untreated, can be fatal.

The condition causes cognitive impairment, motor dysfunction, speech problems and behavioral changes. The main characteristic of ADC is cognitive impairment, which results in mental slowness, trouble with memory and poor concentration. Symptoms of motor dysfunction include a loss of fine motor control, poor balance and clumsiness. Behavioral changes may include apathy (absence of emotion or enthusiasm), lethargy and diminished emotional responses and spontaneity.

In addition, many patients may also experience agitation, anxiety, fatigue, depression or other psychiatric manifestations. Mania and psychosis have been described as presenting symptoms or complications of ADC.

General: Patients who experience ADC symptoms should consult a qualified neurologist who can make a proper diagnosis. The neurologist will first rule out alternative diagnoses. This requires a neurological examination, brain scans (magnetic resonance imaging or computerized tomography scan) and lumbar puncture to evaluate the cerebrospinal fluid.

No single test is available to diagnose patients with ADC. Patients are diagnosed with ADC based on the following criteria:
marked impairment of at least two ability domains of cognitive function (such as memory, concentration or mental slowness); the cognitive impairments interfere significantly with daily activities, and they present for at least one month and do not meet the criteria for delirium; and there is no evidence of another pre-existing disease that is associated with dementia (like a CNS infection or cerebrovascular disease).

Computerized tomography (CT) or magnetic resonance imaging (MRI) scan: A CT scan or MRI of the brain provides a detailed, three-dimensional picture of the brain. These tests can detect brain atrophy (shrinkage) that occurs in ADC patients.

Position emission tomography (PET): Position emission tomography (PET) or single-photon emission computed tomography (SPECT) scans can detect abnormalities in metabolism in the brain that may be associated with ADC.

Lumbar puncture: A lumbar puncture (spinal tap) may be performed to detect abnormalities in the cerebrospinal fluid (CSF). During the procedure, a needle is inserted in the lower back (usually between the third and fourth lumbar vertebrae) and a sample of CSF is removed from the spinal canal. This clear fluid is produced in normal cavities in the brain called ventricles (which are visible on CT scan and MRI). The fluid surrounds the brain and spinal cord, serving as a cushion to protect these structures. The CSF can be tested for various abnormalities that are related to dementia symptoms.

Electroencephalography (EEG): During an electroencephalography (EEG), several electrodes are attached to the scalp. The electrical activity of the brain can be measured. In the later stages of ADC, the electrical activity (which appears as waves) is slower than normal.

Neuropsychological testing: Neuropsychological testing is the most accurate way to assess a patient's cognitive abilities. During the test, the patient answers questions and performs tasks that have been prepared for this purpose. A neurologist, psychologist or other trained professional administers the test. It provides an accurate assessment of cognitive abilities such as memory, attention, orientation to time and place, speech and abilities to follow instructions. Reasoning, abstract thinking and problem solving also are tested.

Highly active antiretroviral therapy (HAART): Highly active antiretroviral therapy (HAART), developed by researchers from the National Institute of Allergy and Infectious Diseases, combines drugs from at least two different classes of antiretroviral drugs. The therapy, which is effective in controlling HIV infection, also protects many HIV-positive people from developing AIDS dementia complex. In some cases, HAART can partially or completely reduce symptoms of ADC.

Several studies have shown that treatment with HAART is more effective than zidovudine (antiretroviral) monotherapy at protecting against ADC. According to many studies, HAART prevents the progression of ADC independent of the drugs' CSF penetration properties. There appears to be no difference in cognitive testing results when single versus multiple CSF-penetrating drugs are used. Also, adding zidovudine, which is the drug with the best CSF penetrance, does not improve the clinical efficacy of the HAART combinations.

Currently, the U.S. Food and Drug Administration (FDA) has approved 29 antiretroviral drugs to treat HIV infected individuals. These drugs fall into three major classes: reverse transcriptase (RT) inhibitors, protease inhibitors and fusion inhibitors. In July 2006, the FDA approved a multi-class combination called Atripla®.

Reverse transcriptase (RT) inhibitors: RT inhibitors disrupt the reverse transcription stage in the HIV lifecycle. During this stage, an HIV enzyme, known as reverse transcriptase, converts HIV RNA to HIV DNA. There are two main types of RT inhibitors. Nucleoside/nucleotide RT inhibitors serve as faulty DNA building blocks, and once they are incorporated into the HIV DNA, the DNA chain cannot be completed. Therefore, the drug prevents HIV from replicating inside a cell. Non-nucleosideRT inhibitors bind to reverse transcriptase, preventing HIV from converting the HIV RNA into HIV DNA. Approved antiretrovirals include Combivir®, Emtriva®, Epivir®, Epzicom®, Hivid®, Retrovir®, Trizivir®, Truvada®, Videx EC® Videx®, Viread®, Zerit®, Ziagen®, Rescriptor®, Sustiva® and Viramune®.

Fusion inhibitors:Fusion inhibitors prevent the virus from fusing with the cellular membrane, thus blocking entry into the cell. Only one fusion inhibitor, Fuzeon®, is FDA-approved.

Zidovudine (Retrovir®): Zidovudine (Retrovir®) is the most-studied reverse transcriptase inhibitor. Since it was first produced in 1987, several studies have consistently shown that zidovudine improves radiologic, neuropsychologic and clinical findings in patients with ADC. However, several studies have shown that treatment with HAART is more effective than zidovudine (antiretroviral) monotherapy at protecting against ADC. Treatment may be administered for as long as three months to 12 years.

Anti-psychotics: Anti-psychotic medications like fluphenazine (Prolixin Decanoate®) and mesoridazine (Serentil®) can improve severe agitation, aggression, hallucinations or delusions, which are often associated with ADC.

Antidepressants: Antidepressants have been used to treat depression associated with dementia. However, they must be used cautiously because they can cause delirium in patients who have dementia. Antidepressants that have the fewest side effects in people with dementia are selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac®) and citalopram (Celexa®).

In-patient care: Patients who have severe ADC may require inpatient care in a nursing home or similar facility.

Ginkgo: Ginkgo biloba has been used medicinally for thousands of years. The scientific literature overall does suggest that ginkgo may benefit people with dementia, and may be as helpful as acetylcholinesterase inhibitor drugs such as donepezil (Aricept®). Well-designed research comparing ginkgo to prescription drug therapies is needed.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Sage: Sage has long been suggested as a possible therapy for memory and cognitive improvement. Several trials provide evidence for the use of sage for this indication. Additional study is needed to confirm these findings and determine the best dose.

Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae (mint) family. Use cautiously with hypertension (high blood pressure). Use sage essential oil or tincture cautiously in patients with epilepsy. Avoid if pregnant or breastfeeding.

Good scientific evidence:

Aromatherapy: Aromatherapy is the use of essential oils from plants for healing purposes. There is suggestive preliminary evidence that aromatherapy using essential oil of lemon balm (Melissa officinalis) may effectively reduce severe agitation in dementia when applied to the face and arms twice daily. Other research reports that steam inhalation of lavender aromatherapy may have similar effects. However, there is a conflicting study that reports no benefits of aromatherapy using lemon balm, Lavender officinalis, sweet orange (Citrus aurantium), or tea tree oil (Malaleuca alternifolia). Overall, the evidence does suggest potential benefits. It is not clear if this is because of anxiety-reducing qualities of these therapies. Additional study is necessary. There is also preliminary research suggesting that aromatherapy used with massage may help to calm people with dementia who are agitated. However, it is not clear if this approach is any better than massage used alone.

Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.

Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine (medicine practiced in India) and is widely used in India for enhancing memory, pain relief, and treating epilepsy. Although bacopa is traditionally used in Ayurvedic medicine to enhance cognition, high-quality clinical trials are lacking. Two methodologically weak studies found some evidence that bacopa improves cognition. However, more high-quality and independent research is needed before bacopa can be recommended for enhancing brain function in adults or children.

Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin®), and drugs metabolized by the liver. Use cautiously
with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.

Ginkgo: Multiple clinical trials have evaluated ginkgo for a syndrome called cerebral insufficiency. This condition, more commonly diagnosed in Europe than the United States, may include poor concentration, confusion, absent-mindedness, decreased physical performance, fatigue, headache, dizziness, depression, and anxiety. It is believed that cerebral insufficiency is caused by decreased blood flow to the brain due to clogged blood vessels. Some studies report benefits of ginkgo in patients with these symptoms, but most have been poorly designed without reliable results. Better studies are needed before a conclusion can be made.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Music therapy: Music is used to influence physical, emotional, cognitive and social well-being and improve quality of life for healthy people as well as those who are disabled or ill. It may involve either listening to or performing music, with or without the presence of a music therapist. In people with dementia and other mental disorders in older adults, music therapy has been found to reduce aggressive or agitated behavior, improve mood, and improve cooperation with daily tasks such as bathing. Music therapy may also be beneficial for dementia-associated neuropsychiatric symptoms, such as depression and aggressive behavior. Music therapy may help maintain mental performance in elderly adults undergoing surgical procedures, reduce postoperative confusion and delirium, and increase energy levels. Music therapy is generally known to be safe.

Unclear or conflicting scientific evidence:

Acupressure, shiatsu: Acupressure may decrease verbal and physical agitated behavior in dementia patients. Further study is needed before a conclusion can be made.

With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. Serious long-term complications have not been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

Acupuncture: Acupuncture has been reported to help improve memory and cognitive performance in the elderly. However, there is currently insufficient available evidence for the use of acupuncture in cognitive disorders and communication disorders. There is also insufficient evidence to recommend the use of acupuncture in the treatment of vascular dementia. More research is necessary.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with a history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Alpha-lipoic acid: In early research, alpha-lipoic acid (ALA) has been studied as a treatment for cognitive impairment caused by nerve damage in HIV patients. However, at this time, there is not enough scientific evidence to recommend ALA for treating cognitive function in HIV.

Avoid if allergic to alpha-lipoic acid (ALA). Use cautiously with diabetes and thyroid diseases. Avoid with thiamine deficiency or alcoholism. Avoid if pregnant or breastfeeding.

Arginine: There is not enough information available to make a strong recommendation about the use of the amino acid arginine in senile dementia.

Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

Astragalus: Based on limited available clinical study, astragalus may improve the mental performance of children with low IQs. However, astragalus was used as part of a combination therapy, and it is difficult to ascribe the effects to any one constituent. Further, well-designed clinical trials are required before recommendations can be made.

Avoid if allergic to astragalus, peas, or any related plants or with a history of Quillaja bark-induced asthma. Avoid with aspirin or aspirin products or herbs or supplements with similar effects. Avoid with inflammation (swelling) or fever, stroke, transplant or autoimmune diseases (like HIV/AIDS). Stop use two weeks before surgery/dental/diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders or kidney disorders. Avoid if pregnant or breastfeeding.

Ayurveda: The herb Brahmi (Bacopa monnieri) is used in many Ayurvedic preparations for a variety of ailments. There is evidence from well-designed studies that it may improve memory and cognitive function in adults. Another study suggests that the herbal preparation Maharishi Amrit Kalash (MAK) -4 may enhance attention capacity or alertness, and thus reverse some of the detrimental cognitive effects of aging. Further research is needed to confirm these results.

Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long period of time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs may interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before use. Use guggul cautiously with peptic ulcer disease. Patients should avoid sour food, alcohol, and heavy exercise with use of this herb. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid amlaki (Emblica officinalis) at bedtime. Avoid Terminalia chebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.

Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine and is widely used in India for enhancing memory, pain relief, and treating epilepsy. However, additional study is needed before a firm conclusion can be drawn.

Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin®), and drugs metabolized by the liver. Use cautiously
with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents, or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.

Beta-carotene: Antioxidants such as beta-carotene may be helpful for increasing cognitive performance and memory. Long-term, but not short-term, beta-carotene supplementation appears to benefit cognition.

Avoid if sensitive to beta-carotene, vitamin A, or any other ingredients in beta-carotene products.

Black tea: Several preliminary studies have examined the effects of caffeine, tea, or coffee use on short and long-term memory enhancement. It remains unclear if tea is beneficial for this use. Limited, low-quality research also reports that the use of black tea may improve mental performance/alertness and cognition.

Black tea contains caffeine, which is a stimulant. Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances/insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.

Boron: Preliminary human studies report better performance on tasks of eye-hand coordination, attention, perception, short-term memory, and long-term memory with the use of boron. Although boron has not been studied in AD, it may be beneficial in improving cognitive function.

Chromium: Early research suggests that chromium picolinate may help improve cognitive function in the elderly. Further study is needed in this area.

Trivalent chromium appears to be safe because side effects are rare or uncommon. However, hexavalent chromium may be poisonous (toxic). Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke, and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.

Cranberry: Preliminary study results show that cranberry juice may increase overall memory enhancement. Further well-designed clinical trials are needed to confirm these results. It is best not to use sweetened cranberry juice or cranberry juice cocktail due to the high sugar content. The use of 100% cranberry juice products is recommended by healthcare providers.

Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.

Creatine: Early studies show that creatine may improve memory in certain populations, such as vegetarians and the elderly. Further research is required before recommendations can be made.

Avoid if allergic to creatine or with diuretics (like hydrochlorothiazide, furosemide (Lasix®)). Use caution in asthma, diabetes, gout, kidney, liver or muscle problems, stroke or with a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.

DHEA: Dehydroepiandrosterone (DHEA) is an endogenous hormone (made in the human body) and secreted by the adrenal gland. DHEA serves as precursor to male and female sex hormones (androgens and estrogens). DHEA levels in the body begin to decrease after age 30 and may need to be taken as supplements. Preliminary evidence, from a controlled trial and a case series, gives conflicting results as to whether DHEA offers benefit to individuals with dementia. Well designed clinical trials, with appropriate endpoints are required before recommendations can be made.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Gingko: There is preliminary research showing small improvements in memory and other brain functions with use of ginkgo in patients with age-associated memory impairment (AAMI), although some studies disagree. Overall, there is currently not enough clear evidence to recommend for or against ginkgo for this condition. It remains unclear if ginkgo is effective for memory enhancement in healthy patients. Further well-designed research is needed as existing study results conflict.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Ginseng: Early small studies report that Fuyuan mixture, an herbal combination that contains ginseng, may improve symptoms of multi-infarct dementia. The effects of ginseng alone are not clear, and no firm conclusion can be drawn. In addition, the use of ginseng for mental performance has been assessed using standardized measurements of reaction time, concentration, learning, math, and logic. Benefits have been seen both in healthy young people and in older ill patients. Effects have also been reported for the combination use of ginseng with Ginkgo biloba. However, some negative results have also been reported. Therefore, although the sum total of available scientific evidence does suggest some effectiveness of short-term use of ginseng for mental performance, better research is necessary before a strong recommendation can be made.

Avoid ginseng with known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

Gotu kola: Ayurveda regards gotu kola (Centella asiatica) as an important rejuvenating herb for nerve and brain cells, believed to be capable of increasing intelligence, longevity, and memory. Limited available clinical study investigated a combination product containing gotu kola on cognitive function in the elderly, but did not find any benefit. Additional study is needed to confirm these findings.

Avoid if allergic to gotu kola, asiaticoside, asiatic acid, or madecassic acid. Avoid with a history of high cholesterol, cancer, or diabetes. Avoid if pregnant or breastfeeding.

Grapeseed: Grape seed oil is a popular (non scented) carrier oil used in aromatherapy. Although grape seed has been compared to lavender oil and thyme oil to reduce agitation in dementia patients, there is not enough scientific evidence to make a conclusion about its effectiveness.

Avoid if allergic or hypersensitive to grapes or other grape compounds. Use cautiously if taking blood thinners such as warfarin, aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), or anti-platelet agents. Use cautiously with bleeding disorders or if taking drugs that may increase the risk of bleeding. Use cautiously with drugs processed using the liver's cytochrome P450 enzyme system. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Avoid with disorders that increase the risk of bleeding or with active bleeding disorders (stomach ulcers, bleeding into the brain, etc.). Avoid if pregnant or breastfeeding.

Green tea: Several preliminary studies have examined the effects of caffeine, tea, or coffee use on short and long-term memory and cognition. It remains unclear if tea is beneficial for this use. Limited, low-quality research reports that the use of green tea may improve cognition and mental performance/alertness.

Green tea contains caffeine, which is a stimulant. Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease.

Guarana: Guarana is a native species of South America and has stimulating properties when taken by mouth. Guarana is also used to enhance athletic performance and to reduce fatigue. Guarana has not been shown to alter cognitive enhancement or arousal in preliminary studies. Caffeine found in guarana may improve simple reaction time, but may not improve immediate memory. Additional study is needed in this area.

Avoid if allergic/hypersensitivite to guarana (Paullinia cupana), caffeine, tannins, or species of the Sapindaceae family. Avoid with hypertension, psychological or psychiatric disorders, liver impairment, and arrhythmias. Avoid with other stimulatory agents, especially ephedra. Use cautiously with breast disease, impaired kidney function, diabetes, pre-existing mitral valve prolapse, iron deficiency, gastric or duodenal ulcers, bleeding disorders, glaucoma or if at risk for osteoporosis. Use cautiously if undergoing electroconvulsive therapy (ECT). Avoid if pregnant or breastfeeding.

Guided imagery: The term guided imagery may be used to refer to a number of techniques, including metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Early research suggests that guided imagery of short duration may improve working memory. Further research is needed before a firm conclusion can be drawn.

Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified healthcare provider if mental or physical health is unstable. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety, or emotional upset because imagery may trigger these symptoms. In patients feeling unusually anxious while practicing guided imagery, or in patients with a history of trauma or abuse, a qualified health care provider should be consulted before practicing guided imagery.

Iodine: Iodine is required for the production of thyroid hormones, which are necessary for normal brain development and cognitive function. Limited available study showed that oral iodized oil significantly improved performance on cognitive tests in 10-12 year-old school children. Further research is needed to confirm these results.

Reactions can be severe, and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis or tuberculosis. Use cautiously when applying to the skin because it may irritate/burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.

Jasmine: Odors and memory improvement are considered to be somehow linked in the brain. Two clinical trials using weakly jasmine-scented rooms found that subjects did not have improved recall of a physical environment without the jasmine odor trigger but could remember a word list better when exposed to a jasmine trigger. More research is needed in this area.

Use cautiously during pregnancy, based on traditional use. Use cautiously in patients allergic to jasmine, jasmine oil, or other fragrances. Use cautiously during lactation as jasmine flowers applied to the breasts have been used as a lactofuge. Avoid oral consumption of essential oils, including jasmine essential oil, as they are extremely potent and can be poisonous.

Jojoba: Jojoba oil is traditionally used as a carrier or massage oil. There is currently not enough available evidence to recommend for or against the use of jojoba oil for dementia.

Avoid if allergic or hypersensitive to jojoba, its constituents, or members of the Simmondsiaceae family. Avoid oral consumption of jojoba products. Avoid if pregnant or breastfeeding.

Khat: Khat is a flowering evergreen plant that has been grown for use as a stimulant for centuries. Khat has been evaluated for its benefits for cognitive function; however, the results are mixed with some studies showing benefit and others showing negative effects. Additional study is needed to clarify these findings. When taken by mouth, it is unknown whether khat is physically addictive. However, it is linked to psychological dependence and is illegal in the United States.

Avoid if allergic to the Celastraceae family (staff vine family). Use cautiously if taking amoxicillin, ampicillin or stimulants. Use cautiously with a history of high blood pressure, fast heartbeat (tachycardia), depression, or motor tics (Tourette's syndrome). Avoid with glaucoma or mental illness. Avoid driving or operating heavy machinery after using khat. Avoid holding khat in the cheek for a long time. Avoid if pregnant or breastfeeding.

Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. Breathing exercises are an important part of Kundalini yoga. There is some evidence from studies with healthy volunteers that use of certain breathing techniques (such as breathing solely through one nostril or the other) may improve different aspects of cognitive function. More studies are needed to determine if these techniques can reliably be used to improve cognitive function and possibly aid in treating cognitive and nervous system disorders.

Avoid exercises that involve stoppage of breath, with heart or lung problems, insomnia, poor memory, or concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Use cautiously with mental disorders as some techniques may cause an altered state of consciousness. Kundalini Yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Lamaze techniques are based on yogic breathing. If started early in the pregnancy, it may be possible to master the ability of breathing to reduce stress and aid in labor. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.

Lavender: Small studies of patients with severe dementia in nursing homes have found that lavender aromatherapy or pinning a cloth to the patient with lavender oil on it may help to decrease agitated behavior. Although lavender is a sedative-type aroma, use during recess periods in a work environment after accumulation of fatigue seemed to prevent deterioration of cognitive performance in subsequent work sessions. Small trials investigating the effects of lavender aromatherapy on agitation and behavior in patients with dementia report conflicting results. Further well-designed studies are needed before a conclusion can be drawn.

Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

L-Carnitine: Most studies of L-carnitine and/or acetyl-L-carnitine for dementia suffer from various weaknesses. Although preliminary evidence is promising, there is insufficient available evidence to recommend for or against this use. There are also a limited number of studies relevant to the use of carnitine for memory. Carnitine does not appear to have any effect on memory. Additional study is needed before a conclusion can be made.

Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

Lemon balm: Limited data is available supporting the use of lemon balm as a treatment for agitation in dementia patients. Additional study is necessary before a conclusion can be drawn. Clinical data suggest that the use of standardized lemon balm (Melissa officinalis) extract has some effect on particular self-reported measures of mood and cognitive performance. More rigorous studies need to be conducted using patient-relevant outcomes to better assess the validity of these results as they apply to patient care. Based on available research, lemon balm taken by mouth has been reported to be relatively well tolerated when taken for up to eight weeks. Evidence for topical administration of lemon balm cream suggested minimal side effects for up to 10 days of application.

Avoid if allergic or hypersensitive to lemon balm. Avoid with Grave's disease or thyroid hormone replacement therapy. Use cautiously in glaucoma because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.

Macrobiotic diet: Macrobiotics is a predominantly vegetarian, whole-foods diet that emphasizes whole grains (especially brown rice), vegetables, fruits, legumes, and seaweeds. The evidence is mixed as to whether or not a macrobiotic diet helps, hinders, or has no effect on cognitive function in children.

There is a risk of nutrition deficiencies with use of an exclusive macrobiotic diet; however, this can be avoided with appropriate menu planning. Use cautiously with cancer or other medical conditions without expert planning or supplementation. Macrobiotic diets are not recommended in children or adolescents without professional guidance or appropriate supplementation, and are also not recommended in pregnant or lactating women due to potential deficiencies, unless properly supplemented.

Massage: Massage with or without essential oils has been used in patients with dementia in chronic care facilities to assess effects on behavior. There is compelling early evidence that aromatherapy with essential oils may reduce agitation in patients with dementia, although the effects of massage itself are not clear.

Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

Meditation: Some forms of meditation may have positive effects on cognitive function. However, there is not enough clear evidence that any specific form of meditation can support or enhance cognitive function.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

Melatonin: Melatonin is a naturally occurring hormone that helps regulate sleep/wake cycles (circadian rhythm). There is limited study of melatonin for improving sleep disorders in dementia patients. Further research is needed in this area before a firm conclusion can be reached.

Based on available studies and clinical use, melatonin is generally regarded as safe in recommended doses for short-term use. Melatonin should be avoided in patients using warfarin, and possibly in patients taking other blood-thinning medications or with clotting disorders. Melatonin may cause drops in blood pressure. Caution is advised in patients with high cholesterol levels, atherosclerosis, those at risk for cardiovascular disease, diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar. Mild gastrointestinal distress commonly occurs, including nausea, vomiting, or cramping. Patients with glaucoma taking melatonin should be monitored by a healthcare professional. Melatonin should be avoided in women who are pregnant or attempting to become pregnant; high levels of melatonin during pregnancy may increase the risk of developmental disorders. In men, decreased sperm motility and decreased sperm count are reported with use of melatonin.

Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, or linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single 6-ounce meal per week, and in young children to less than 2 ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat 7 ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

Policosanol: The effects of policosanol supplementation on reactivity and related brain activity have been examined. Although there is early compelling evidence, further research is necessary before a clear conclusion can be made.

Avoid if allergic or hypersensitive to policosanol. Use cautiously if taking aspirin or blood pressure medications. Use cautiously with high blood pressure. Use cautiously if pregnant or breastfeeding.

Polypodium leucotomos extract and anapsos: Extracts of the polypodium fern have been used for many health conditions. It is commonly found in South America and Europe. The South American species Polypodium leucotomos L. is also known as "calaguala." Extracts of this species are called "anapsos." Limited scientific information is available about the effectiveness of polypodium in the treatment of dementia.

Avoid if allergic or hypersensitive to ferns from the family Polypodiaceae. Use cautiously with heart disease or with use of blood pressure drugs. Avoid operating any heavy machinery when taking polypodium. Avoid if pregnant or breastfeeding.

Reiki: Early research suggests that Reiki therapy may improve behavioral and memory problems in patients with mild cognitive disorders. However, additional studies are needed to confirm these findings.

Reiki is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.

Rhodiola: Early human study suggests that rhodiola may benefit learning, memory, and mental performance. Well-designed studies are needed before a recommendation may be made.

Avoid if allergic or sensitive to Rhodiola. Use cautiously in people with diabetes, cardiovascular disease, or neurological or psychiatric disorders. Rhodiola is not recommended for use during pregnancy or breastfeeding.

Rhubarb: Preliminary study has investigated rhubarb along with other herbs in the treatment of age-associated memory impairment (AAMI). Studies of rhubarb alone are needed to discern rhubarb's effect on aging and memory.

Avoid if allergic/hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, pre-eclampsia, renal disorders, ulcerative colitis, and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12 due to water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking anti-psychotic drugs or oral drugs, herbs or supplements (including calcium, iron, and zinc). Avoid if pregnant or breastfeeding.

Riboflavin: Adequate nutrient supplementation with riboflavin (vitamin B2) may be required for the maintenance of adequate cognitive function. Treatment with B-vitamins including riboflavin has been reported to improve scores of depression and cognitive function in patients taking tricyclic antidepressants. This may be related to tricyclic-caused depletion of riboflavin levels.

Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as safe during pregnancy and breastfeeding. The U.S. Recommended Daily Allowance (RDA) for riboflavin in pregnant women is higher than for non-pregnant women, and is 1.4 milligrams daily (1.6 milligrams for breastfeeding women).

Soy: It is unclear if soy isoflavone supplementation in postmenopausal women may improve cognitive function. Results from available studies are mixed.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk (not specifically designed for infants). People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy.

Traditional Chinese medicine: Traditional Chinese medicine (TCM) herbal combinations have been used for the treatment of dementia and reportedly improve cognitive function and activities of daily living. More studies of better design are needed before recommendations can be made.

Acupuncture is generally considered safe. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurologic disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Turmeric: Curcumin has been shown to have antioxidant and anti-inflammatory properties and to reduce beta-amyloid and plaque burden in lab studies. However, there is currently not enough evidence to suggest the use of curcumin for cognitive function.

Avoid if allergic or hypersensitive to turmeric, curcumin, yellow food colorings, or plants belonging to the Zingiberaceae (ginger) family. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, diabetes, hypoglycemia, or gallstones. Use cautiously with blood-thinners, such as warfarin (like Coumadin®), and blood sugar-altering medications. Avoid in medicinal amounts if pregnant or breastfeeding. Turmeric should be stopped prior to scheduled surgery.

Vitamin E: Vitamin E has been proposed and evaluated for the prevention or slowing of dementia, based on antioxidant properties and findings of low vitamin E levels in some individuals with dementia. Overall, the evidence remains inconclusive in this area.

Vitamin E may cause bleeding, especially in sensitive individuals such as those taking medications for bleeding disorders (including warfarin or Coumadin®). Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid use above the recommended daily level in pregnant and breastfeeding women.

Yoga: There is limited human study of yoga for memory improvement. Better studies are needed before a conclusion can be made.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Fair negative scientific evidence:

Bitter orange: Bitter orange has been used in aromatherapy, although it does not appear to reduce combative, resistive behaviors in individuals with dementia. Currently, evidence supporting the use of bitter orange for dementia and behavioral challenges is lacking.

Avoid if allergic or hypersensitive to bitter orange or any members of the Rutaceae family. Avoid with preexisting cardiovascular (heart) disease, narrow-angle glaucoma, and intestinal colic. Avoid using if taking anti-adrenergic agents, beta-blockers, or QT-interval prolonging drugs or with long QT interval syndrome. Avoid if taking antidepressants, with drugs or dietary supplements with stimulant properties, and with honey. Use bitter orange preparations that are applied to the skin cautiously with fair skin. Use cautiously with headache and hyperthyroidism (too much thyroid hormone). Avoid if pregnant or breastfeeding.

DHEA: Studies of the effects of dehydroepiandrosterone (DHEA) on memory have produced complex and inconsistent results. Additional study is warranted in this area.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Gingko: The results of limited available study investigating the effect of Ginkgo biloba on post-prandial mental performance are unclear. Ginkgo may benefit some but not all endpoints. Further clinical trials are required before a conclusion can be made.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Highly active antiretroviral therapy (HAART), developed by researchers from the National Institute of Allergy and Infectious Diseases, combines drugs from at least two different classes of antiretroviral drugs. The therapy, which is effective in controlling HIV infection, also protects many HIV-positive people from developing ADC. The therapy has led to a decline of ADC in developed countries. The frequency of ADC has declined from 30-60% of people infected with HIV to less than 20%.

While the progression of dysfunction is variable, ADC can be fatal if left untreated.

Stage 0 (normal): The patient has normal mental and motor function.

Stage 0.5 (subclinical): The patient experiences mild cognitive or motor dysfunction symptoms, such as slowed extremity movement. However, symptoms do not interfere with the patient's ability to perform daily activities. Gait and strength are normal.

Stage 1 (mild): There is evidence of cognitive or motor dysfunction that characteristic of ADC. Patients may experience mental slowness, trouble with memory, poor concentration, as well as loss of fine motor control, reduced balance and clumsiness. Symptoms do not interfere with the patient's ability to perform activities of daily living. However, the patient may experience difficulty with rigorous physical or mental activities.

Stage 2 (moderate): The patient experiences moderate ADC symptoms. The patient is able to perform basic self-care activities. Patients at this stage can walk, but may require a mobility cane. The patient cannot maintain the more demanding aspects of daily life.

Stage 3 (severe): The patient experiences severe cognitive dysfunction and cannot sustain complex conversations. Motor dysfunction is also severe. The patient cannot walk without the help of a walker or personal support. Motor skills are significantly slower and clumsier than normal.

Stage 4 (end stage): The ADC patient is almost in a vegetative state. Intellectual and social comprehension is severely dysfunctional. At this stage, most patients are nearly or completely mute. The patient may be paraparetic (partial paralysis of the lower half of the body) or paraplegic (complete paralysis of the lower half of the body). Patients may also be incontinent (unable to control excretion of both urine and feces).

Patients who have ADC should try to remain as intellectually, socially and physically active as possible.

Patients are encouraged to engage in daily physical exercise. This helps patients maximize their motor and mental functions.

Patients are encouraged to engage in as much mental activity as possible. Keeping the mind working may help reduce symptoms of cognitive dysfunction. For instance, puzzles, games, reading and crafts may help stimulate the brain.

Maintaining a social life is also important. Interacting with friends and family may help keep the mind active and emotions in balance.

The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.